Radiology Management Program for High-Tech Outpatient Diagnostic Imaging Procedures

Fallon Health partners with eviCore healthcare to provide authorization services for high-tech outpatient elective diagnostic imaging procedures for your patients. Authorization is required for CT scans (including CTA), MRI/MRA studies, Nuclear Cardiac Imaging (NCM), and PET scans.

Which high-tech outpatient diagnostic imaging procedures are included?

Notification is accepted for the following outpatient diagnostic imaging procedures:

• CT scan (including CTA)
• MRI/MRA
• Nuclear Cardiac Imaging (NCM)
• PET scan

How can I submit requests to eviCore healthcare ?

You can submit your authorization requests to eviCore healthcare for outpatient diagnostic imaging procedures by phone at 1-888-693-3211 or by fax at 1-888-693-3210 during normal business hours 8 a.m. to 9 p.m. EST. You can also submit them through eviCore healthcare's secure website.

The portal has helpful radiology reference information for your office such as a complete CPT code list, diagnostic code list, and specific guidelines to assist you in determining the most appropriate imaging for your patient’s condition. In addition to these benefits, the eviCore healthcare portal offers you:

• Convenience - Requestors have 24/7 access to submit notification or check on the status of your request.
• Speed - Requests submitted online require half of the time (or less) than those taken telephonically. Notifications can often be processed immediately.
• Efficiency – Medical documentation can be attached to the case upon initial submission, reducing follow-up calls and consultation.
• Real Time Access - Requestors can see real-time status of a notification.
• Patient History - Requestors can see existing and previous notifications for a member.

How does the eviCore healthcare program work?

For routine scans, the ordering physician should contact eviCore healthcare prior to the procedure being scheduled and performed. The request will be immediately processed or additional information will be requested. Upon receipt of this information, eviCore healthcare will render a decision within two (2) business days or as required by federal or state regulations.

Where can I obtain a copy of the clinical guideline used in my case?

You may contact eviCore healthcare to request a copy of the specific guideline used in your case. All eviCore healthcare guidelines are available through eviCore healthcare's documents library online.

Is authorization required for imaging studies related to inpatient or emergency care?

No. It is not necessary to contact eviCore healthcare to preauthorize any imaging procedure performed during an inpatient stay, observation, or emergency room visit.

What is eviCore healthcare's response time?

eviCore healthcare may require up to two business days after receipt of sufficient clinical information to review a request. In certain cases, the review process can take longer if additional clinical information not supplied during the request is needed for review.

The best way to increase the possibility of having a notification completed at the time of the first call is to have knowledge of the case including:

• The patient’s name & address and Fallon Health member ID,
• Prior tests, labwork, and/or imaging performed related to this diagnosis,
• Notes from the patient’s last visit related to the diagnosis,
• Type and duration of treatment performed to date for the diagnosis,
• The patient’s history and diagnosis,
• Reason for study,
• Results of previous imaging studies, and
• History of medical or surgical treatment.

Tip: The body part and modality-specific fax forms provide an indication of what clinical information might be required.

Can eviCore healthcare handle multiple requests per phone call?

Yes, within reason. We ask that no more than 10 requests be given during a single phone call. You may prefer the convenience of the Web, available 24/7 for batching pre-authorization requests (https://www.evicore.com/provider).

Are physicians required to call eviCore healthcare before they call to schedule an appointment?

No.

What if my office has an urgent need for imaging?

For urgent imaging needs, authorization is required. However, the review time-frame can be expedited by calling eviCore healthcare. Please indicate clearly that the request is for medically urgent care.

What does the eviCore healthcare authorization number look like?

It is an 8-digit alphanumeric value (e.g. A1234567).

What happens if a patient is preauthorized for a CT of the abdomen, and the radiologist or rendering physician feels an additional study of the pelvis is needed?

The radiologist or rendering physician should proceed with the pelvic study. The radiologist or designated person from the radiology facility may then contact eviCore healthcare to submit the change. As a matter of courtesy and appropriate medical procedure, the radiologist or designated person from the radiology facility should also notify the patient's referring physician of the additional test.

What happens if a patient is authorized for a CT without and with contrast but the radiologist determines that the contrast is not necessary?

There is no need to notify eviCore of contrast changes. All manner of contrast will be covered under the authorization.

What about procedure(s) that do not go through eviCore healthcare for notification?

Physicians should continue to refer to Fallon Health policies for all services.

What is the SmartChoice High-tech Radiology program?

SmartChoice is applicable to our fully insured commercial HMO members.It is a high-tech radiology (CT, MRI) program administered by our high-tech radiology vendor, eviCore healthcare. As a built-in component of your standard communication with eviCore healthcare for such screenings, eviCore healthcare will recommend more affordable high-tech radiology facilities you might use when you select a higher-cost location for your initial request.

Whom should I contact with questions?

• If you have additional questions about the radiology management program, please contact eviCore healthcare at 1-888-693-3211.

View and download clinical guidelines and fax forms »

For additional details about SmartChoice, please call 1-866-275-3247, write to askfchp@fallonhealth.org, or refer to the Radiology Prior Authorization Utilization and Management Guide.

SmartChoice MRI facilities

*Available for current patients only. This list is reviewed on a regular basis and is subject to change.

SmartChoice CT Scan facilities

*Available for current patients only. This list is reviewed on a regular basis and is subject to change.